Resolving the Gatekeeper ConundrumWhat Patients Value in Primary Care and Referrals to Specialists

Author Affiliations: Department of Family and Community Medicine (Dr Grumbach), Primary Care Research Center (Drs Grumbach and Bindman), Center for California Health Workforce Studies (Drs Grumbach and Bindman), and the Department of Internal Medicine (Dr Bindman), University of California, San Francisco; the Division of Research, Kaiser Permanente Medical Care Program of Northern California, Oakland (Drs Selby and Quesenberry and Mss Truman and Uratsu); and the Pacific Business Group on Health, San Francisco (Dr Damberg).

Context Few data are available regarding how patients view the role of primary
care physicians as "gatekeepers" in managed care systems.

Objective To determine the extent to which patients value the role of their primary
care physicians as first-contact care providers and coordinators of referrals,
whether patients perceive that their primary care physicians impede access
to specialists, and whether problems in gaining access to specialists are
associated with a reduction in patients' trust and confidence in their primary
care physicians.

Design, Setting, and Patients Cross-sectional survey mailed in the fall of 1997 to 12,707 adult patients
who were members of managed care plans and received care from 10 large physician
groups in California. The response rate among eligible patients was 71%. A
total of 7718 patients (mean age, 66.7 years; 32% female) were eligible for
analysis.

Main Outcome Measures Questionnaire items addressed 3 main topics: (1) patient attitudes toward
the first-contact and coordinating role of their primary care physicians,
(2) patients' ratings of their primary care physicians (trust and confidence
in and satisfaction with), and (3) patient perceptions of barriers to specialty
referrals. Referral barriers were analyzed as predictors of patients' ratings
of their physicians.

Results Almost all patients valued the role of a primary care physician as a
source of first-contact care (94%) and coordinator of referrals (89%). Depending
on the specific medical problem, 75% to 91% of patients preferred to seek
care initially from their primary care physicians rather than specialists.
Twenty-three percent reported that their primary care physicians or medical
groups interfered with their ability to see specialists. Patients who had
difficulty obtaining referrals were more likely to report low trust (adjusted
odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence
(OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2
) with their primary care physicians.

High-quality primary care is the foundation of effective and efficient
health care systems. Essential elements of the practice of primary care include
accessibility as the first-contact point of entry to the health care system,
continuity, comprehensiveness, coordination of referrals, and understanding
of the family and community context of health.1- 6
Managed care organizations in the United States have tended to emphasize 2
of these tasks: providing first-contact care and coordinating referrals. Physicians
performing these tasks are often referred to as "gatekeepers."7,8
This term frequently has pejorative connotations in the United States due
to concerns that the cost-containment imperatives of managed care encourage
primary care physicians to restrict rather than facilitate access to specialists
and other referral services. In 1997, almost half of all privately insured
patients in major metropolitan regions throughout the United States were in
"gatekeeping arrangements in which their primary care physician controls their
access to specialists."9 The role of managed
care gatekeepers in the United States has been especially contentious because
of the use of economic incentives that may financially reward primary care
physicians for thrifty use of referral and hospital services.10,11

A recent study found that dissatisfaction with access to specialty care
was the strongest predictor of patients' intention to leave managed care plans.12 Concern about restricted access to specialists and
other referral services has contributed to a mounting public backlash against
managed care.13,14 Public confidence
in primary care physicians in the United States may become a casualty of this
backlash if patients come to view primary care physicians as mere instruments
for impeding access to specialists. Some managed care plans have reacted to
the backlash by offering policies that allow patients direct access to specialists.
Legislative proposals at both the national and state levels, commonly referred
to as patient bills of rights, often feature regulations
to permit patients to circumvent their primary care physicians when seeking
specialty services.13,15 Critics
of these proposals worry that direct access measures may undermine the beneficial
aspects of primary care physicians as coordinators of specialty services.

Limited research suggests that primary care physicians themselves have
considerable ambivalence about their role as gatekeepers in managed care systems.16- 20
However, little is known about how patients view the role of primary care
physicians as coordinators of care. We investigated patient attitudes toward
the involvement of their primary care physicians in access to specialty care.
Our specific objectives were to determine the extent to which patients valued
the role of their primary care physicians as first-contact providers and coordinators
of referral services, whether patients perceived that their primary care physicians
or medical groups impeded access to specialty care in managed care systems,
and whether problems in gaining access to specialty care were associated with
a reduction in patients' trust and confidence in their primary care physicians.

METHODS

Data for this study derived from a cross-sectional survey in the fall
of 1997 of patients in managed care plans who received their care from 1 of
several large medical groups in California. The study was conducted as part
of a broader project investigating patient, physician, and organizational
factors associated with specialty referrals for patients with 1 of 3 medical
conditions (congestive heart failure, benign prostatic hypertrophy, or peptic
ulcer disease and related gastric conditions).

A multistep sampling
strategy was used to select patients for the survey. We began by recruiting
medical groups in California that were willing to provide administrative data
on physician visits and to allow us to survey enrolled patients and primary
care physicians in the group. Ten physician groups agreed to participate,
including 3 independent practice associations, 3 integrated medical groups,
and 4 physician groups affiliated with 1 large, group-model health maintenance
organization. We analyzed administrative records on primary care physician
encounters for the period January 1, 1995, through December 31, 1996, to detect
patients diagnosed as having 1 of the 3 study conditions. These records were
available for patients in health maintenance organizations enrolled in the
group on a capitated basis. We focused on patients with these specific conditions
(1) to reduce the amount of variation in underlying medical conditions that
might complicate analyses of referral issues and (2) to focus on patients
for whom referrals might be a common consideration. We preferentially included
patients who had recently received their initial diagnosis of the study condition.

We selected patients for the study by including all patients
in the medical group with the study conditions up to a maximum of 450 patients
per condition per medical group. This process produced a list of 13,393 patients
potentially eligible for the study. We then mailed each primary care physician
a list of the patients from the physician's practice that we planned to survey.
We asked the physicians to indicate patients who had died, who were too ill
or mentally incapacitated to respond, or who were no longer in that physician's
practice. Six hundred eighty-six patients were excluded from the survey sample
based on feedback from physicians. Questionnaires were mailed to the remaining
12,707 patients.

The questionnaires included items investigating
3 main areas of interest: (1) patient attitudes toward the first-contact and
coordinating role of their primary care physicians, (2) patient ratings of
their primary care physicians, and (3) patient perceptions of barriers to
specialty referrals. Four items addressed patients' attitudes toward the first-contact
and coordination roles of their primary care physicians. Three of these items
were rated on a 5-point scale ranging from "strongly agree" to "strongly disagree":
(1) "I value having 1 primary care physician who knows about all my medical
problems"; (2) "It is helpful for my primary care physician to participate
in decisions about whether I should see a specialist"; and (3) "For most new
medical problems, I can decide for myself whether I should see my primary
care physician or a specialist." A fourth item assessed patients' propensity
to seek initial care from specialists rather than their primary care physicians
for a series of hypothetical medical conditions; this item asked patients
to indicate whether they would prefer to see their primary care physicians
or relevant specialists first in the event they experienced "cough with wheezing
that has lasted for 1 week," "arthritis in your knee causing swelling and
pain," and "blood in your bowel movement." A summary score was created by
assigning patients a point for each of the 3 scenarios in which they preferred
to see a specialist first (range of summary score, 0-3). (This score is hereafter
identified as the "referral propensity score.") The Cronbach α test
for the referral propensity score was .70.

Patients were asked
to rate the performance of their primary care physicians on 3 commonly evaluated
dimensions: trust, confidence in quality of care, and overall satisfaction.
Patients were asked to indicate their level of agreement (using a 5-point
scale ranging from "all of the time" to "none of the time") with the statements,
"I trust my primary care physician to do what is best for me," and "My primary
care physician is well qualified to manage, diagnose and treat medical problems
like mine." They were also asked to indicate their overall satisfaction with
care from their primary care physicians on a 5-point scale ranging from "very
satisfied" to "very dissatisfied." Although trust, confidence, and satisfaction
are related constructs, prior research has validated that these 3 items measure
distinct and important dimensions of physician performance and the patient-physician
relationship.3,21- 24

The final content area, barriers to referral, was evaluated using 2
items. One item asked about patients' level of agreement with the general
statement, "My primary care physician or medical group sometimes interferes
with my ability to see specialists." Responses were coded as agreeing with
this statement if the patient did not indicate disagreement (that is, if the
response was either "agree" or "uncertain" as opposed to "disagree"). Another
item inquired about the patient's actual experience of referral barriers.
Patients were asked whether they had thought they needed referrals from their
primary care physicians to specialists in the prior year. Patients who indicated
that they had needed referrals were then asked to rate their ease or difficulty
in obtaining referrals; response choices were "very easy," "easy," "difficult,"
"very difficult," "so difficult I was unable to get the referral I wanted,"
and "I did not try to get the referral." These 2 sets of items on referral
barriers differed in a few important ways. The first item ("My primary care
physician or medical group sometimes interferes . . . ") was asked of all
patients irrespective of whether they had actually needed a referral in the
prior year; the item also attributed responsibility to physicians or medical
groups for interfering with referrals. The second item, asked only of patients
who had actually needed referrals in the past year, specifically asked about
their experiences with those referrals and did not include comments of attribution
for difficulties in obtaining the referrals. We validated the question on
difficulty obtaining a referral by comparing responses with actual use of
specialty care among patients in the group-model health maintenance organization,
the only patients for whom comprehensive automated encounter data were available.
The mean number of visits to specialists in the prior year was much greater
among patients reporting no difficulty obtaining a referral than among those
reporting some level of difficulty (4.03 vs 2.93; P<.001).

Logistic regression models were used to test the association
between referral barriers and the 3 main outcome variables (patient ratings
of trust and confidence in and satisfaction with their primary care physicians).
Models were designed to predict low ratings on these 3 outcome variables,
defined as any value less than "all" or "most of the time" for the trust and
confidence variables and a rating of dissatisfaction or uncertainty on the
satisfaction item. Included as predictors in these models were the variables
on referral barriers; the referral propensity score; variables measuring patient
demographic characteristics (age, sex, education, marital status, race/ethnicity)
and health status (overall self-rated health status, a Charlson comorbidity
score,25 and variables for each of the 3 study
conditions); variables measuring elements of the patient-physician relationship
(duration of care with the primary care physician, whether the patient chose
or was assigned to the primary care physician, and the availability of the
primary care physician to answer questions during the day); and dummy variables
for each specific medical group. Logistic regression models used parameter
estimation by the generalized estimating equation approach to account for
clustering of patients within individual physician practices.26

RESULTS

Of the 12,707 patients surveyed, 8394 (66%) returned completed questionnaires.
Of the patients not returning questionnaires, we ascertained that 854 were
not eligible for the survey because they had died (191), did not speak English
(85), were no longer enrolled with the medical group (105), had moved and
gave no forwarding address (301), or were otherwise ineligible (172). The
adjusted response rate after excluding these additional ineligible patients
was 71% (8394/11,853). Among survey respondents, 676 patients were excluded
from data analysis because they indicated that their current physicians were
not in the study's physician panel, resulting in a total of 7718 patients
for the final analyses.

The mean age of study participants was
older than 65 years, and almost 30% of participants rated their health as
only fair or poor (Table 1), reflecting
the study's focus on patients with medical conditions that increase in prevalence
with age. The relatively low proportion of women in the study is attributable
to the inclusion of benign prostatic hypertrophy as 1 of the study conditions.
The racial and ethnic distribution of patients was comparable to that of the
overall insured population of California, excepting a somewhat lower proportion
of Latino patients. Two thirds of patients had chosen their primary care physicians,
and half had been with their physicians for at least 5 years.

Almost all patients valued the
role of a primary care physician as a source of first-contact care and coordinator
of referrals (Table 2). Ninety-four
percent of patients agreed that they valued having primary care physicians
who knew about all of their medical problems. Almost as many patients (89%)
agreed that it was helpful for their primary care physicians to participate
in decisions about specialty referrals. Fewer than half (46%) of the patients
agreed that they could decide for themselves in most instances whether to
see a specialist; 28% of patients disagreed with this statement, while 26%
reported that they were uncertain or did not know whether they could usually
decide for themselves to see a specialist without first consulting their primary
care physicians.

On the set of items evaluating
patients' propensity to seek first-contact care from a specialist rather than
their primary care physician, from 75% to 91% of patients preferred to visit
their primary care physicians first, depending on their specific medical problems
(Figure 1). Sixty-seven percent
of patients indicated that they would seek initial care from their primary
care physicians for all 3 of the problems combined.

Twenty-three percent of patients agreed with the statement
"My primary care physician or medical group interferes with my ability to
see specialists." When asked specifically about whether they thought they
had needed referrals in the prior year, 67% of patients answered in the affirmative.
Among those patients who thought they needed referrals, 12% reported that
it was difficult to get the referrals they wanted, 82% indicated that it was
easy to get the referrals, and 7% reported that they "hadn't tried" to get
the referrals. Agreement with the general statement about referral barriers
was highly correlated with each patient's own experience with a needed referral.
Seventy-five percent of patients who needed referrals and reported them as
being difficult to obtain also agreed with the statement that their physicians
or medical groups interfered with access to specialists, compared with 18%
of patients who reported an easy time getting the referrals they wanted and
17% of patients who said they had not needed referrals in the past year (P=.001).

Patients' ratings of their primary
care physicians revealed generally high levels of trust, confidence, and satisfaction.
Eighty-five percent of patients reported that all or most of the time they
trusted their primary care physicians to do what is best for them, and 82%
believed that all or most of the time their physicians were well qualified
to manage their care. A similar proportion (82%) of patients were satisfied
with their primary care physicians.

In multivariate regression
analyses of factors associated with low ratings of trust, confidence, and
satisfaction, experiences or perceptions of referral barriers emerged as 1
of the strongest independent predictors of lower patient ratings of their
primary care physicians (Table 3).
Compared with patients who said they did not need referrals, patients who
had needed referrals and encountered difficulty obtaining them were much more
likely to report low trust (odds ratio [OR] 2.7; 95% confidence interval [CI],
2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction
(OR, 3.3; 95% CI, 2.6-4.2). Patients who needed referrals and reported that
it was easy to get them had ratings of trust, confidence, and satisfaction
that were comparable to those for patients who did not need referrals. Patients'
propensity to want referrals, as measured by their preference for first-contact
care from specialists, was also strongly and independently associated with
their ratings of their primary care physicians; patients with higher referral
propensities rated their primary care physicians lower on the trust and confidence
items (Table 3). The referral
propensity score was also associated with lower satisfaction, although not
as strongly as with the trust and confidence scales. Consistent with prior
research on the patient-physician relationship, patients who chose their physicians,
who had longer relationships with their physicians, and who reported that
their physicians were more available to answer questions were less likely
to report low ratings of trust, confidence, and satisfaction.3,21,27

We repeated these regression
analyses, substituting the more general referral barrier question ("My primary
care physician or medical group interferes . . . ") for the item inquiring
about actual experience with needed referrals. Patients who agreed that their
physicians or medical groups interfered with referrals were more likely to
report low trust (OR, 2.0; 95% CI, 1.7-2.4), low confidence (OR, 1.9; 95%
CI, 1.6-2.3), and low satisfaction (OR, 2.0; 95% CI, 1.7-2.3). We also repeated
the analyses limiting the sample to only those patients who indicated that
they had chosen their primary care physicians. The referral experience variable
remained strongly associated with lower ratings of primary care physicians
in analyses performed only on this subgroup of patients. Finally, because
men were overrepresented in our study sample relative to their proportion
in the overall population, we stratified the sample by sex to determine whether
effects differed according to patients' sex. Difficulty obtaining referrals
remained a significant predictor of low trust, confidence, and satisfaction
in all models for each sex, although the ORs for this effect tended to be
larger among women.

COMMENT

Health policy debates are often framed as "either-or" propositions.
Do patients value primary care, or do they value specialty care? Our study
suggests that the answer is that patients value both. Patients overwhelmingly
endorsed the importance of having identified primary care physicians to integrate
their overall care and preferred to involve their primary care physicians
in decisions about obtaining care from specialists. Most patients also preferred
to initiate care for new medical problems with their primary care physicians
rather than seeking care directly from specialists. These responses indicate
that patients perceive a beneficial role for primary care physicians in coordinating
their care, suggesting that most patients do not generally endorse a model
of fragmented specialty care without primary care physicians integrating this
care.

Patients also clearly want to be able to obtain specialty
care when they believe they need it. A small but noteworthy proportion of
patients perceived their primary care physicians or medical groups to be impediments
to specialty care. Most of these patients had actually experienced difficulty
obtaining referrals that they believed they needed. Perceptions of referral
barriers were 1 of the strongest predictors of patients giving their primary
care physicians low trust, confidence, and satisfaction ratings. Other studies
have shown that low ratings on these types of measures are associated with
some important outcomes, such as poorer adherence to treatment and worse health
status outcomes in chronic disease.3,28,29

Several limitations of our study merit comment. As in any cross-sectional
observational study, causal inferences must be made cautiously. Our results
may indicate that the experience of a referral barrier results in patients
having lower trust and confidence in their primary care physicians. An alternative
interpretation is that patients who have underlying distrust of or dissatisfaction
with their physicians are more likely to perceive barriers to referrals. Several
findings support the former interpretation. We attempted to measure patients'
underlying preference for specialty care using a referral propensity score.
This score likely captures components of patients' predispositions to distrust
or lack confidence in their primary care physicians. It was strongly associated
with patients' ratings of their physicians, in that patients who were more
inclined to seek specialty care reported lower confidence, trust, and satisfaction.
However, in models that adjusted for the referral propensity score, the experience
of a referral barrier remained a strong predictor of lower physician ratings.
In addition, we reanalyzed the data including only patients who actively chose
their primary care physicians, thereby limiting the sample to patients who
each presumably had sufficiently high initial regard for their physician to
voluntarily enroll in that physician's practice. The referral barrier variables
remained strong predictors of lower ratings in this sample.

Our
study included patients who were enrolled only in managed care plans and who
each had an identified primary care physician. If patients who prefer a more
primary care–oriented model are more likely to enroll in managed care
plans, our study may have a selection bias toward patients with more favorable
views of primary care physicians. Our study design also selected for patients
with a higher level of illness than the general population. Although these
patients may have greater needs for referrals, they may also be more likely
than healthier patients to have established ongoing relationships with their
primary care physicians. Because of the sampling design, our results are not
necessarily generalizable to all patients in these medical groups or to the
population at large.

Our findings have important policy implications.
Many health care systems, such as the British National Health Service, have
long emphasized the virtues of primary care, fostering a medical culture in
which patients have grown accustomed to registering with family physicians
and routing most of their medical needs through those physicians' practices.30 In the United States, the principle of a primary
care coordinator of services has been less ingrained in the health care system.
In the pre–managed care era, the values of specialty care dominated
the medical culture, leading many insured Americans to expect unfettered access
to specialists of their choice. Many advocates of primary care in the United
States welcomed the ascendance of managed care as a force that would value
and enhance the practice of primary care. Although managed care has placed
primary care physicians in a more prominent role in the current US health
care system, the role of gatekeeper has been a mixed blessing. Overemphasis
of primary care gatekeepers as agents of cost control threatens to undermine
primary care in the United States.11

The challenge in the United States is to create practice arrangements
that promote a first-contact and coordinating role for primary care physicians
without simultaneously casting primary care physicians in the role of rationer
of specialty care. Some analysts have proposed redefining the role of the
primary care physician in the United States from that of gatekeeper to conductor,31,32 reaffirming the central role of primary
care physicians as coordinators of a health care team. This redefinition would
involve elimination of financial incentives that allow primary care physicians
to profit by withholding referrals and relaxation of strict prior-authorization
rules for specialty visits. At the same time, specialists would be expected
to effectively communicate with primary care physicians and to recognize the
importance of primary care physicians as integrators of care. Resolving the
gatekeeper conundrum also will require addressing many of the underlying structural
problems in the US health care system, such as an overabundant supply of specialists,
that contribute to this predicament.